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FARS/DFARS Restrictions Apply to Government Use. American Medical Association,
515 N. State St, Chicago, IL 60610.
Volume 160(16)
11 September 2000
pp 2429-2436
Outline
Abstract
CLINICAL IMPLICATIONS OF POTASSIUM DEPLETION
PROTECTIVE EFFECT OF POTASSIUM
HYPOKALEMIA
Graphics
General Guidelines
Patients With Hypertension
Patients With CHF
Patients With Cardiac Arrhythmias
Patients Prone to Stroke
Patients With Diabetes Mellitus
Patients With Renal Impairment
References
Table 1
Table 2
Table 3
Table 4
Abstract
This article is the result of a meeting of the National Council on Potassium in Clinical
Practice. The Council, a multidisciplinary group comprising specialists in cardiology,
hypertension, epidemiology, pharmacy, and compliance, was formed to examine the
critical role of potassium in clinical practice. The goal of the Council was to assess the
role of potassium in terms of current medical practice and future clinical applications.
The primary outcome of the meeting was the development of guidelines for potassium
replacement therapy. These guidelines represent a consensus of the Council members
and are intended to provide a general approach to the prevention and treatment of
hypokalemia.
Arch Intern Med.2000;160:2429-2436
5.0 mmol/L. The loss of just 1% (35 mmol) of total body potassium content would
seriously disturb the delicate balance between intracellular and extracellular potassium
and would result in profound physiologic changes. On the other hand, the presence of
hypokalemia (ie, serum levels <3.6 mmol/L) is not necessarily synonymous with wholebody potassium deficiency, because such a small percentage of the total body stores is
present in extracellular fluid. Whereas it is generally accepted that diuretic therapy can
decrease serum potassium to hypokalemic levels, the subtler effects of inadequate
dietary potassium are less well known.
For instance, although young adults may consume up to 3400 mg (85 mmol) of
potassium per day, many elderly individuals, particularly those living alone or those
who are disabled may not have a sufficient amount of potassium in their diet. People
who eat large amounts of fruits and vegetables tend to have a high potassium intake of
approximately 8000 to 11,000 mg/d (200-250 mEq). Urban whites typically consume
approximately 2500 mg (62.5 mEq) of potassium daily. In contrast, many African
Americans have low intakes of about 1000 mg (25 mEq) per day. 1 The daily minimum
requirement of potassium is considered to be approximately 1600 to 2000 mg (40-50
mmol or mEq). Factors that affect potassium intake include the type of diet consumed
(Table 1), age, race, and socioeconomic status.
renal failure. Such complications are most often seen in hypokalemia secondary to
alcoholism.
HYPOKALEMIA
Clinical Implications in Hypertension
Evidence from epidemiologic and clinical studies has implicated potassium depletion in
the pathogenesis and maintenance of essential hypertension. 16 Increasing the intake of
potassium appears to have an antihypertensive effect that is mediated by such
mechanisms as increased natriuresis, improved baroreflex sensitivity, direct
vasodilation, and lower cardiovascular reactivity to norepinephrine or angiotensin II. 17
Indirect support for this hypothesis comes from observations of the effects of primary
impose a stricter standard for treatment (potassium <4.0 mmol/L) especially in patients
with heart disease who are at risk for serious ventricular tachyarrhythmias. For example,
the risk of early ventricular fibrillation in acute myocardial infarction is strikingly
increased in patients with serum potassium levels less than 3.9 mmol/L. 34-37 However,
there are no data to prove that aggressive replenishment of potassium in patients with
heart disease necessarily leads to a better clinical outcome.
Since potassium supplements are typically indicated for long-term use, it is important to
optimize patient adherence." 45
Reported adverse effects of potassium supplements affect primarily the gastrointestinal
tract, and they include nausea, vomiting, diarrhea, flatulence, and abdominal pain or
discomfort. Ulcerations of the small bowel have been reported after the administration
of enteric-coated potassium chloride tablets. A few cases of small bowel ulceration,
stricture, and perforation have been associated with wax-matrix formulations. 47
Although slow-release tablets have been associated with gastrointestinal tract
ulcerations and bleeding, the risk of these complications is low and seems to be lowest
with the use of microencapsulated preparations. 2
practices for the use of potassium. The guidelines were developed at a 1998 meeting of
the National Council on Potassium in Clinical Practice. It is clear that controlled clinical
studies are necessary to determine the specific recommendations.
General Guidelines
1. Dietary consumption of potassium-rich foods should be supplemented with potassium
replacement therapy. Often, increasing dietary potassium intake is not completely
effective in replacing the potassium loss associated with chloride depletion (eg, that
which occurs in diuretic therapy, vomiting, or nasogastric drainage) because dietary
potassium is almost entirely coupled with phosphate, rather than with chloride. In
addition, the consumption of potassium-rich foods in amounts that are sufficient to
increase the level of serum potassium level to acceptable concentrations may be costly,
and it may lead to weight gain.
2. Potassium replacement is recommended for individuals who are sensitive to sodium
or who are unable or unwilling to reduce salt intake; it is especially effective in
reducing blood pressure in such persons. A high-sodium diet often results in excessive
urinary potassium loss.
3. Potassium replacement is recommended for individuals who are subject to nausea,
vomiting, diarrhea, bulimia, or diuretic/laxative abuse. Potassium chloride has been
shown to be the most effective means of replacing acute potassium loss.
4. Potassium supplements are best administered orally in a moderate dosage over a
period of days to weeks to achieve the full repletion of potassium.
5. Although laboratory measurement of serum potassium is convenient, it is not always
an accurate indicator of total body potassium. Measurement of 24-hour urinary
potassium excretion is appropriate for patients who are at high risk (eg, those with
CHF).
6. Patient adherence to potassium supplementation may be increased with complianceenhancing regimens. Microencapsulated formulations have no unpleasant taste and are
associated with a relatively low incidence of gastrointestinal side effects.
7. Potassium supplementation regimens should be as uncomplicated as possible to help
optimize long-term compliance.
8. A dosage of 20 mmol/d of potassium in oral form is generally sufficient for the
prevention of hypokalemia, and 40 to 100 mmol/d sufficient for its treatment.
Data suggest a link between potassium levels and lesions of the kidneys in patients with
renal disease or diabetes. Animal studies have demonstrated that potassium may offer a
protective effect on the renal arterioles. The clinical implications of these findings are
not yet clear.
Accepted for publication February 28, 2000.
This article is based on a symposium supported by a grant from Key Pharmaceuticals,
Kenilworth, NJ.
The National Council on Potassium in Clinical Practice participants include: Jay N.
Cohn, MD,Department of Medicine, University of Minnesota Medical School,
Minneapolis; Peter R. Kowey, MD, Department of Cardiology, Lankenau Hospital and
Medical Research Center, Wynnewood, Pa, Department of Medicine, Jefferson Medical
College, Philadelphia, Pa; Barry J. Materson, MD, Department of Medicine, University
of Miami, Miami, Fla; L. Michael Prisant, MD, Department of Medicine, Director of
Cardiology Fellowship Training, Medical College of Georgia, Augusta; Elijah Saunders,
MD, Department of Medicine, Hypertension Division, University of Maryland School
of Medicine, Baltimore; Dorothy L. Smith, PharmD, President, Consumer Health
Information Corporation, McLean, Va, Department of Community and Family
Medicine, Georgetown University School of Medicine, Washington, DC; Louis Tobian,
MD, Department of Medicine, Division of Hypertension, University of Minnesota
Medical School, Minneapolis; and Paul K. Whelton, MD, Tulane University School of
Public Health and Tropical Medicine, New Orleans, La.
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